People with schizophrenia differ on the degree to which they are aware of having an illness and this can impact behavior. A small percentage of those with schizophrenia get violent and it seems that this violence is most likely to happen during periods of active psychosis. Doctors and legal experts go back and forth as to whether patients can be held accountable for such violent acts while they are actively psychotic. Similarly, the role of �insight� into ones illness has also been debated. �Insight� into illness is defined as �an awareness of having an illness, an attribution of recognizable symptoms of that illness and an appreciation of the need for treatment�.

This study looked at the extent and pattern of insight deficits in patients with schizophrenia who are violent. Using different questionnaires, the authors asked 115 patients with schizophrenia who were in a jail or court psychiatric clinic to answer questions about their symptoms, illness severity, insight into illness and insight into the legal consequences of their illness ("forensic insight"). They also included a sample of nonviolent patients with schizophrenia in order to have a comparison group. The authors report that they went through reviews by institutional review boards, extensive discussions with jail warden and municipal judges and social workers in order to protect the rights of the patients.

The results confirmed that the overall risk of violent crimes committed by people suffering from schizophrenia is small and that most incidents are of low lethality. In this study, the most common offense by violent patients with schizophrenia was felonious assault, with 1/3 of offenses being committed against a law enforcement officer and � against a known person or relative. The majority of violent patients also had active psychotic symptoms and were abusing substances at the time of the violent incident. Also, compared to the nonviolent group, violent patients had poorer functioning and had a more prominent lack of insight which was related to having a lack of forensic insight (ie a lack of awareness of the legal consequences of their actions). This distinction is important because legal debates regarding competency are often based on the extent to which illness-related variables affect the understanding of the crimes committed by individuals with mental illnesses.

This study suggests that for patients with a history of violence it may be helpful to try interventions (eg cognitive behavior therapy) that focuses on helping improve insight into illness and the legal consequences of the illness. Such medication and psychological treatments can also be preventive in helping improve insight and possibly avoiding future acts of violence during psychotic episodes.